Provider Demographics
NPI:1104247485
Name:PHILLIPS, GARY M (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 CHESTNUT ST
Mailing Address - Street 2:APT. 20G
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:259 WEST PL
Practice Address - Street 2:
Practice Address - City:TOWNSHIP OF WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07676-4738
Practice Address - Country:US
Practice Address - Phone:201-358-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05998600208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice